Assessing Medical Tourism Services Quality Using SERVQUAL Model: A Patient’s Perspective

Background: Continuous quality improvement of the hospital services is a basic requirement of medical tourism industry. The different dimensions of hospital services quality are assessed constantly to improve the service of medical tourism. The aim of this study was to determine the services quality of medical tourism in private and public hospitals. Methods: In this cross-sectional study, the quality of hospital services were assessed in view of 250 Iraqi tourists referred to Ahvaz private and public hospitals in 2015. Data were collected using a valid medical tourism SERVQUAL questionnaire (MTSQ). This questionnaire includes 8 main dimensions with 31 items. Finally, Mann-Whitney, Kruskal-Wallis and Wilcoxon tests were used to analyze the data. Results: The mean of age of patients was 39±2.2 yr. The mean of hospital length of stay was 3.87±1.36 days. The most patients were admitted to Orthopedics, Otorhinolaryngology, Obstetrics, and Gynecology departments, respectively. There was a negative gap in all of the dimensions of service quality in the studied hospitals (P>0.001). The highest and lowest quality gap was seen in the “exchange and travel facilities” (−2.63) and the “tangibles” (−0.68) dimension, respectively. Conclusion: There was a negative gap in all of the dimensions of service quality in the studied hospitals. Therefore, the hospital services quality is improved to attract the foreign patients.


Introduction
Medical tourism is one expression of globalization (1). The term "medical tourism" is widely defined for the provision of medical care in collaboration with the tourism industry for patients who need medical services outside their country (1,2). For example, some of the Asian countries including India, Thailand, and Singapore are the major destinations for medical tourists (2,3). The main reasons to choose these countries as a medical tourism destination are low cost medical services and experienced doctors (3,4). In 2007, an estimated 50 000-120 000 patients of the United States travelled abroad to obtain medical care to Asia, South America, and Eastern Europe (5). In these countries, even uninsured patients based on their treatment can save about 15% to 85% of the costs (6). According to the fourth economic and social development plan, Iran's ministry of health must provide the necessary facilities for marketing of health services to earn more income (7). In Iran, opportunities such as high quality of medical ser-vices, low cost of medical services, access to new medical technology, and experienced health professionals can help to develop medical tourism industry (8). Quality of medical services has a significant impact on attracting medical tourists (1,2). Today the assessing and improving quality of services is one of the basic managerial tasks in the service sector (8). One of the most useful and applied methods to measure services quality is global SERVQUAL questionnaire. This common questionnaire used to measure the gap of services quality based on the patient's expectation and perception (9). This tool was used to assess services quality. Most studies reported the service quality gap in private and public hospitals by SERVQUAL methods (10)(11)(12)(13). In Iran, most studies reported a negative gap of hospital services quality based on the SERVQUAL method (8,11,12). The aim of current study was to determine the services quality gap between medical tourism in Ahvaz public and private hospitals. Ahvaz is one of the metropolises of southern Iran bordered by Iraq. In This metropolis, thirteen public and private hospitals admit foreign patients as medical tourism hospitals (13).

Materials and Methods
In this cross-sectional study, the quality of hospital services was assessed in view of 250 Iraqi tourists referred to Ahvaz private and public hospitals in 2015. Census data were collected using a valid medical tourism SERVQUAL questionnaire (MTSQ). This questionnaire was designed based on basic SERVQUAL model (14). The medical tourism SERVQUAL questionnaire included 31 items and 8 dimensions (tangibles, reliability, responsiveness, assurance, empathy, exchange and travel facilities, technical and infrastructure facilities and safety and security). A questionnaire was translated into Arabic and English. This tool can measure the gap between patients' expectations and perceptions. The 5point Likert scale was used to measure hospital services quality in view of patients. Likert points of perceptions and expectations were rated from 1 = strongly disagree to 5 = strongly agree. Content validity of the questionnaire was confirmed using the Delphi technique and expert's opinions (CVI=0.775). The construct validity of the questionnaire was confirmed using confirmatory factor analysis (RMSEA=0.032, CFI= 0.98, GFI=0.88). Reliability of the questionnaire using Cronbach's alpha was confirmed (α=0.837 for expectation, α=0.919 for perception). The patient compleated the expectation questionnaires before admission and perceptions questionnaires after discharge, respectively. The gap of hospital service quality was measured using the following formula: Gap=Perception-Expectation If: E>P => Negative gap If: E<P => Positive gap Finally, the data were analyzed by SPSS (Ver. 18 Chicago, IL, USA). Data were analyzed by nonparametric tests, including Mann-Whitney, Kruskal-Wallis and Wilcoxon tests. The significance level of study was 0.05. This research was approved by Ethical Committee of Ahvaz Jundishapur University of Medical Sciences.

Results
The mean of patients' age was 39±2.2 yr. The mean of length of stay was 3.87±1.36 d. Orthopedics, Otorhinolaryngology, Obstetrics, and Gynecology departments had the most admitted patients respectively. About 82.8% of patients were uninsured. Out of 250 patients who participated in the study, 131 patients (52.4%) have not visited our hospitals before. There was no significant relationship between the gap in medical tourism service quality dimensions and patients' demographic characteristics (Table 1). Assessing the gap between patients' perception and expectation in eight dimensions of medical tourism service quality showed that the expectation of Iraqi medical tourists was more than their perception in all the dimensions; therefore, the quality gap of studied hospital services was negative. There was the highest and the lowest quality gap in the "exchange and travel facilities" dimension (-2.63) and the "tangibles" dimension (-0.68), respectively ( Fig. 1). All items had a negative gap. The highest quality gap was seen in "The website provides adequate information about treating illness" (G=-2.96) and "Payment facilities are easy and flexible" (G=-2.87) items, respectively. The lowest gap was seen in "neat and well-dressed personnel" (G=-0.66) and "modern and up-to-date equipment" (G=-0.68) items, respectively ( Table 2).  According to Table 3, the gap was negative and statistically significant, in all dimensions (P<0001). The highest gap was reported in "ex-change and travel facilities" dimension (G=-2.63) and lowest gap was reported in "tangibility" dimension (G=-0.68) ( Table 3).

Discussion
The aim of this study was to determine the services quality of medical tourism in hospitals. According to SERVQUAL model, service quality gap was determined by measuring the differences between patient's expectation and perception (10,11). There was the negative gap for all dimensions of service quality in studied hospitals that providing medical tourism services. This means that medical tourists' expectations were more than their perceptions about quality of medical service and they were not satisfied with hospital services. In this study, tangibles (including physical evidence) had the lowest negative gap of services quality between other dimensions. In this dimension, there was a significant difference between perception and expectation of patients. The patients' expectation was more than their perception in "tangibles" dimension about hospital services (12). In American medical centers, the gap between patients' perception and expectation of service quality was also negative, but this gap was not statistically significant (15). Hospitals can play a key role in attracting medical tourists using advanced and standardized medical equipment and devices (16).
In the dimension of reliability, the service quality gap was also negative. A negative and significant difference between patients' expectation and their perception in reliability of hospital services (10). Naqavi et al. reported a gap in service quality in Iranian hospitals (16). Reliability is one of the important dimensions of services quality. This dimension includes doing duties in accordance with the commitments, interesting employees in doing tasks and service provision, doing services correctly at the first visit of patients, providing the services on promised time, maintaining records of clients accurately, and increase trust between hospitals and medical tourists (17). Hospitals should improve the reliability of their services to increase patients' loyalty.
In the current study, responsiveness dimension had also negative gap in view of patients. The mean of perception was less than expectation in responsiveness dimension in Iranian private hospitals (11). In American rehabilitation centers, the gap between the quality of services in responsiveness dimension was positive (18). Providing prompt service to patients is an important element in the responsiveness and patients had more satisfaction from hospitals that determine the time of treatment and provide prompt services (19,20).
In assurance dimension, the difference between patients' perception and expectations of hospital service was negative. The study in allergy clinics in Poland showed the negative gap in this dimension (21). In all developed countries, quality assurance committee of the hospitals assesses assurance of the services quality. Recently in Iran, hospitals establish quality improvement committees to control their clinical and services quality and initial steps have been taken to quality improvements (22). In empathy dimension, the difference between patients' perception and expectations of hospital service was negative. This difference was statistically significant. In Iran, a significant difference was indicated in empathy dimension of the hospital service quality (23). The gap between patients' perception and expectation was positive in empathy dimension (24). Empathy is considered as the main domain of quality associated with non-clinical aspect of healthcare (25). To reduce the gap in empathy dimension, non-medical expectations should be developed by hospitals. These non-medical needs include dignity, confidentiality, autonomy, and communication (26).
There was a negative gap in "exchange and travel facilities" dimension in view of foreign patients. The quality gap of this dimension was negative in the Indian public and private hospitals (27). Existing payment facilities in hospitals have a massive impact on the patient satisfaction and most patients consider this item before traveling to the destination country; therefore, it is necessary to increase exchange and travel services in the hospital (28). The study showed that there was gap between patients' perception and expectation in technical and infrastructure facilities dimension and this dimension was unsatisfactory for medical tourists. Hospital staff had no international experience and could not speak English and other foreign languages. To increase the foreign patients' confidence, only reputation and scientific knowledge of doctors and professional staff are not enough and all aspects of professional staff should be improved. In the safety and security dimension of medical tourism service quality, there was a negative gap between perception and expectations of patients. Therefore, patients were not satisfied in term of hospital safety and security. Personnel behavior, social security and communication variables were respectively the most important factors to attract medical tourist (29). Appropriate prescription is one of the patients' safety strategies in hospitals. Prescription and medication management were appropriate in Iranian private hospitals (27). Patient safety is the key indicators of hospital accreditation and quality improvement. Promoting patient's safety led to improving hospital performance (30,31). This study had several limitations: First, the generalization of study to other hospitals is a problem. Second, all studied patients were from Iraq.

Conclusion
There was a negative gap in all of the dimensions of services quality in the studied hospitals in Ahvaz. This means that studied hospitals could not met the patients' expectation. The highest gap in the medical tourism service quality was observed in "exchange and travel facilities" dimension and the lowest gap was observed in the "tangibles" dimension. Therefore, studied hospitals should improve their quality of services based on gap score of services quality and improve their weakness. Finally, hospitals should promote national and international standards of medical tourism.

Ethical considerations
Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.
Chancellor for Research Affairs of Ahvaz Jundishapur University of Medical Sciences. The authors appreciate all people who helped them in this study, especially Dr. Mehran Haghparast (head of medical tourism office in Ahvaz Jundishapur University of Medical Sciences).